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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.MMaan fe t Tracking Number �1�[ WASTE MANIFEST IJ ;U C. .,I JL 3`9`�1 S K 5.Generator's Name and Mailing Address Generator's Site Address(If different than marling address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8-Designated Facility Name and Site Address U.S EPA ID Number Facillit es Phone. ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Pecking Group(f any)) No, Type Quantity INt.fVoI 1. Z 2.LU 1 I 3. 4. I -- - --7 14.Special Handling Instructions and Additional Information 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplecarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter.I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)IN I am a small quantity generator)is true. Generator'slOfferor's PrintedlTyped Name Signature Month Day Year J 16.International Shipments F ❑Import to U.S. Export from U.S Port of entrylexit: __.. Z Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day 'ear O a QTransporter 2 PrintedlTyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ty ❑Type ❑ 1 ❑Full Rejection ❑ Quantl a Residue Par,.al Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA Io Number J V LL Facility's Phone: W 18c.Signature of Ahemate Facility(or Generator) Month Dav Year C- Z N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a rinted/Typed Name Signature Monln Dav Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY